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Metropolitan Life Insurance Company v. Cotter (Lawyers Weekly No. 10-044-13)

NOTICE:  All slip opinions and orders are subject to formal revision and are superseded by the advance sheets and bound volumes of the Official Reports.  If you find a typographical error or other formal error, please notify the Reporter of Decisions, Supreme Judicial Court, John Adams Courthouse, 1 Pemberton Square, Suite 2500, Boston, MA 02108-1750;  (617) 557-1030; SJCReporter@sjc.state.ma.us <bbsdir:13Mar_15.SJC> SJC‑11135   <toc><cname>Metropolitan Life Insurance Company v. James M. Cotter</cname><cite>464 Mass. ?</cite></toc> <toc><cname>James M. Cotter (Metropolitan Life Insurance Company v.)</cname><cite>464 Mass. ?</cite></toc> <name> METROPOLITAN LIFE INSURANCE COMPANY  vs.  JAMES M. COTTER. <endname> <appfrom>Middlesex.     <argudate>November 5, 2012.  ‑  <decdate>March 15, 2013. <present>Present:  <sc>Ireland, C.J., Spina, Cordy, Botsford, Gants, Duffly, </sc>& Lenk</sc>, JJ. <catchwds> <idxtop1>Insurance, <idxtop2>Disability insurance, <idxtop2>Construction of policy, <idxtop2>Coverage.  <idxtop1>Contract, <idxtop2>Insurance, <idxtop2>Unjust enrichment.  <idxtop1>Damages, <idxtop2>Restitution.  <idxtop1>Restitution.  <idxtop1>Unjust Enrichment. <hdn>   <prior> Civil action commenced in the Superior Court Department on September 28, 2007.   The case was heard by Thomas P. Billings, J.   The Supreme Judicial Court granted an application for direct appellate review.   <cnsl> Praven Shenoy for the defendant. Joseph M. Hamilton (David L. Fine with him) for the plaintiff. Julie Simon Miller, of the District of Columbia, & Jeffrey L. Williams, for America’s Health Insurance Plans, amicus curiae, submitted a brief.       LENK, J.  After paying disability benefits to the defendant, James M. Cotter, for several years, the plaintiff, Metropolitan Life Insurance Company (MetLife), determined that Cotter had failed to satisfy a clause in his “own occupation” disability insurance policy that required him to receive care by a physician that “is appropriate for the condition causing the disability.”[1]  Interpreting this clause as requiring Cotter to pursue treatment aimed at returning him to his prior occupation, MetLife advised Cotter that the care he was receiving was not appropriate because it expressly disavowed a return to his prior occupation, and, indeed, was focused on a “return to work in [an] alternate occupation.”  MetLife informed Cotter that it would continue to pay him benefits under a reservation of rights during the pendency of the litigation, and filed an action in the Superior Court seeking a judgment declaring that it had no continuing obligation to pay benefits to Cotter and reimbursement of benefits it had paid under the unilaterally asserted reservation of rights.  Cotter filed counterclaims for violations of G. L. c. 93A and G. L. c. 176D.   Following a jury-waived trial, a Superior Court judge directed the entry of a judgment declaring that, because Cotter was not receiving care “appropriate for the condition causing the disability,”  MetLife was not required to continue paying him benefits, but declaring also that MetLife was not entitled to restitution of any benefits paid.  The judge denied Cotter’s counterclaims and his motion for reconsideration.  The judge also […]

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Posted by Massachusetts Legal Resources - March 15, 2013 at 11:34 pm

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